浏阳农村居民健康状况与农村卫生服务现状综合研究
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摘要
第一篇研究背景与意义
农村卫生工作是关系到提高全民族素质、保障农村生产力、振兴农村经济、维护农村社会发展和稳定的重要工作。新中国成立后,政府大力发展卫生事业,广泛建立了基层卫生体系,形成了集预防、医疗、保健于一体的农村三级(县、乡、村)公共卫生服务网络和农村卫生队伍。农民健康水平得到较大提高,传染病发病率、婴幼儿死亡率、孕产妇死亡率明显下降,期望寿命不断提高。但是农村卫生工作仍面临着资金投入不足、卫生人才匮乏、基础设施落后的问题。随着人口老龄化进程加快,生活水平的提高,环境、心理、社会等的综合影响,慢性病对农民健康的影响越来越突出,医疗费用负担不断增加,农民因病致贫、返贫问题仍然突出。
目前我国农村卫生服务存在的主要问题:①经费投入不足:政府卫生经费投入不足,不仅导致了我国农村卫生资源的严重不足,而且导致农村居民的医疗卫生负担越来越重。②农村卫生专业技术队伍缺乏:农村卫生人力资源不足一是人员总数量上不足,二是专业技术水平低,三是在地区分布上不均衡;同时农村预防保健人员业务素质偏低,缺乏专业培训,年龄结构偏大难以适应卫生服务需求。③乡镇卫生院公共卫生服务功能弱化:乡镇卫生院是承担乡镇公共卫生工作的主要机构,是农村公共卫生服务体系的关键环节,也是目前非常薄弱的环节,一方面是预防保健机构不健全、人员配备不到位;另一方面是预防保健费用不足,公共卫生服务难以开展,导致整个农村预防保健服务网功能低下,同时因受经济利益驱使,扩大了预防保健有偿服务范围和标准,从而加重了人民群众的负担。④农村卫生服务的可及性与均衡性差:农村偏远地区医疗卫生机构的缺失是农村卫生服务可及性差的最主要原因;政府投入不足、市场经济条件下利益驱动等因素导致公立医疗机构的公益性几乎消失,是农村卫生服务不均衡的重要原因;而农民健康意识不强,有了病也不先去正规医院检查治疗,成为农村卫生服务不均衡和可及性差的另一潜在因素。⑤新型农村合作医疗虽已取得较好的效果,但也存在合作医疗基金筹集困难且标准偏低和实际操作缺乏规范的问题。大多数患者由于能报销医疗费用的比例有限而放弃治疗,新农合并未起到抵御疾病风险的作用。
国外对农村及偏远地区的卫生服务问题研究重点:①农村偏远地区卫生人力资源的培养、补充和稳定:面临农村卫生队伍不稳、技术人员缺乏的现实,很多国家采取的最主要也是最有效的手段是:重视开展农村社区医生的技能培训,提高服务能力;在农村办医学院校或由医学院从农村定向招收医学生为农村培养人才,或增加有农村卫生服务经历的人员来学校接受培训的办法。②农村社区的医疗卫生服务利用:国际专家在研究农村社区的医疗卫生服务利用率不高问题时发现,农村居民患者对卫生服务机构的选择与其主观感受和判断有很大关系,农村地区医院的设备水平、经营状况、服务能力与范围等都会影响农村病人特别是老年患者的医疗保健;并提出加强农村卫生服务网络建设,加强农村社区医院与大型医疗中心的合作,是满足农村居民卫生服务需求的重要途径。
国内针对有关农村卫生服务体系建设、农村卫生服务需求与利用、农村卫生人才队伍建设、农村公共卫生现状、新型农村合作医疗、农村传染病与慢性病的防治、乡镇卫生院服务功能定位、村卫生室服务现状的研究较多。但是在疾病谱发生改变、慢性病已成为威胁农民健康的最主要因素后,没有针对地区居民健康状况与当地卫生资源配置以及卫生服务开展情况的综合的、系统的研究,尤其缺乏对乡(镇)、村两级卫生机构的系统研究。我国仍是一个农业大国,农业人口占全国人口的2/3,农村居民的健康问题是最大的民生问题,如何发展农村公共卫生服务与基本医疗服务,实现人人享有基本医疗卫生服务,是各级政府和广大卫生工作者努力追求的目标。卫生部先后三次开展国家卫生服务调查,对于促进我国卫生改革与发展,制定卫生事业发展规划,合理配置卫生资源,提高居民健康水平产生了积极影响。但由于我国幅员辽阔,各地区间的经济发展不平衡,卫生资源分布很不均衡,人们的文化水平、生活水平、健康水平等均不尽相同,各地方仍需参照国家卫生事业发展规划,并根据各地的现状与卫生服务需求制订相应的卫生发展规划。因此,开展地方性的居民健康状况和卫生服务调查对制定地方性卫生事业发展规划具有现实指导意义。浏阳市是湖南省地处湘东的山区革命老区县级市,民营经济活跃,经济发展较快;除血吸虫病外其它的各种传染病、地方病、慢性病等健康问题、居民生活水平与习惯、人口构成等与全省相似,而卫生资源配置与卫生服务水平也接近全省平均水平,在湖南省具有较好的代表性。我们于2006年12月-2007年5月对浏阳市农村居民进行了健康状况、疾病经济负担以及卫生服务利用调查,并对全市所有乡镇卫生院和村卫生室进行普查,为制定符合浏阳市社会经济发展的农村卫生政策提供依据,为进一步完善湖南省农村公共卫生政策、促进农村公共卫生工作提供参考。
第二篇浏阳市农村居民健康调查
目的:研究浏阳市农村居民慢性病的疾病谱及主要慢性病经济负担,农村居民两周患病率及卫生服务利用现况;农村妇女生殖道感染状况和主要影响因素,农村妇女妇科肿瘤的危险因素。
方法:采用分层整群抽样的方法确定浏阳镇头镇、三口乡和杨花乡(代表经济好、中、差)为研究对象,首先进行慢性病筛查,然后从筛查出的10种主要慢性病中随机抽样选取一定数量的病例进行慢性病经济负担的深入调查,调查方式为问卷调查和病历查阅相结合;采用整群抽样方法对3个乡镇的3个村3200余名农村居民进行两周内伤病情况及寻求卫生服务情况调查,内容包括家庭成员的社会人口学特征,居民在调查的前两周内患病情况,以及因患病而寻求卫生服务情况,就诊机构的选择及其原因,未就诊的原因等;采用病例对照的研究方法,对73名筛查获得的农村妇科肿瘤病例和140例对照进行有关月经史、婚育史、既往史、家族史等因素的调查分析,对所得资料进行单因素分析和多因素分析;采用系统整群抽样方法对3个乡镇各抽取2个共6个村的已婚的育龄妇女进行普查,内容包括一般人口学资料和个人卫生习惯,卫生服务利用情况以及常规妇科检查。
结果:①浏阳农村居民慢性病患病率达到160.62‰,慢性病前10位的疾病为高血压、泌尿系统结石症、类风湿关节炎、慢性支气管炎、慢性胃肠炎、冠心病、椎间盘疾病、脑血管疾病、糖尿病、胆囊炎及胆石症;高血压、类风湿关节炎、慢性阻塞肺病、冠心病、椎间盘疾病、脑血管疾病、糖尿病、胆囊炎及胆石症的患病率均高于2003年全国农村平均水平;全市10种主要慢性病的经济负担分别为:高血压病的经济负担最高,达到7180.71万元,其次分别为泌尿系统结石(5129.63万元)、椎间盘疾病(3190.46万元)、脑血管疾病(3144.06万元)、慢性支气管炎(3045.76万元)、类风湿关节炎(2933.20万元)、胆囊炎胆石症(2828.04万元)、糖尿病(2794.56万元)、冠心病(2741.88万元)和慢性胃肠炎(2287.87万元)。以上10种慢性病2006年全市的总经济负担合计达到3.53亿元,人均负担达到296元,占年浏阳2006年农民人均消费性支出4614元的6.4%。每名患者的平均经济负担为2800元,占人均消费性支出4614元的60.7%。②浏阳农村居民两周患病率为152.3‰,略高于国家2003年卫生调查结果农村居民两周患病率139.5%o,其中慢性病持续到两周内的占74.8%;农村居民两周内患病后,有51.6%的患者到医院就诊,其中到村卫生室和乡镇卫生院两级卫生机构所占比例达到64.4%;患者未就诊的主要原因是自感病轻占52.9%、经济困难占26.0%和无有效措施占16.5%。③单因素分析结果发现:农村妇女妇科肿瘤有关的共同危险因素为月经期有痛经、已绝经、绝经后服用激素类药物、哺乳、服用避孕药避孕、患有妇科炎症、患有其他慢性疾病史;多因素分析显示:服用避孕药(OR=11.800,95.0%C.I(1.870～74.476)、患有妇科炎症(OR=11.800,95.0%C.I(2.245～62.032)是农村妇女妇科肿瘤发病的独立的危险因素。④浏阳市农村妇女生殖道感染率为41.4%,疾病构成以慢性宫颈炎和阴道炎为主,分别占了68.3%和31.1%;35～50岁组的生殖道感染率最高,为45.6%;偶尔或不清洗患生殖道感染的危险是经常洗的1.59倍;农村妇女出现生殖道感染症状后,仅18.9%到医院就诊;
结论:①浏阳农村居民慢性病患病率高于全国2003年农村居民慢性病患病率;慢性病谱与全国农村居民慢性病谱近似;浏阳农村10种主要慢性病给患者带来较大的经济负担。②慢性病成为农村居民的最主要的健康威胁;距离近成为其选择就诊单位时首要影响因素;农村患者因健康维护意识不强、看病贵经济压力大、慢性病难治愈等原因而放弃医治。③反复妇女生殖道感染是妇科肿瘤共同的危险因素。④浏阳市农村妇女生殖道感染率与国内相关调查结果接近;农村妇女生殖道感染防治的重点人群和高危人群是35-50岁已婚妇女;缺乏个人卫生知识和良好的性卫生习惯是农村妇女生殖道感染的主要影响因素:农村妇女出现生殖道感染症状后卫生服务利用率偏低;浏阳妇幼保健院近十多年来的普查普治政策仍将是提高农村妇女生殖健康的有效措施之一。
第三篇浏阳市乡镇卫生院和村卫生室卫生服务现状调查
目的:通过对浏阳市乡镇卫生院和村卫生室基本建设情况与业务开展情况调查,为促进乡镇卫生院和村卫生室发展提供依据:了解浏阳农村当前儿童免疫规划工作现状,为评价浏阳农村公共卫生工作落实情况提供依据。
方法:对浏阳市36所乡镇卫生院的基本情况、卫生技术人员情况、基本医疗和公共卫生服务开展情况、近五年经费收入支出情况等进行全面调查;对浏阳市687所村卫生室进行普查,主要内容包括村卫生室基本情况、收支情况、农村公共卫生工作开展情况等;对镇头、三口、杨花三个乡镇从2003年1月1日至2005年12月31日出生的儿童共计630名儿童进行基础免疫和加强免疫接种情况的调查,并对计划免疫专业队伍建设、接种管理与资料建档等进行定性调查。
结果:①浏阳市36所乡镇卫生院平均服务人口为36790人,平均每千服务人口的卫生技术人员1.5人;乡镇卫生院的卫生技术人员占职工总数比例88%;公共卫生服务人员院均值为3.8人;36所乡镇卫生院2005年的病床使用率为平均58.9%,年均诊疗18463.9人次;近5年来,乡镇卫生院公共卫生收入的2/3来源于预防接种:乡镇卫生院职工最多196人,最少仅7人,病床最多170张,最少的仅6张,业务用房面积多的10900m~2,少的仅400m~2,固定资产最多的2146万元,最少仅41万元。;②687所村卫生室共有卫生服务人员1158人、村医757人,每千服务人口有村卫生服务人员0.89人、村医0.58人,50岁以上村医占52.3%,无专业学历的的卫生服务人员占54.8%;36.7%的村卫生室业务用房面积低于45m~2,业务用房面积最大的有200 m~2,最小的只有1 m~2,相差200倍;固定资产最大值为150.0万元,最小为0.1万元,相差1500倍;687所村卫生室的药品收入占总收入的76.8%;村卫生室公共卫生工作主要是疫情报告、健康教育、接种通知、出生与死亡上报等工作。③三个乡共有计划免疫专职人员5人,总服务人口98383人,计划免疫专职人员平均配置比例0.51/万人;三个年龄组的平均建卡率为90.5%,平均建证率为86.7%;三个年龄组儿童的“四苗”基础免疫全程接种率为75.06%,其中卡介苗(BCG)接种率91.52%,脊灰疫苗(OPV)接种率86.49%,百白破(DPT)接种率83.91%,麻疹疫苗(MV)接种率81.08%。儿童“四苗”基础免疫全程接种率2003—2005年分别为79.35%、76.74%、69.53%;三年龄组乙肝疫苗全程接种率84.3%;三年龄组的平均儿童百白破和麻疹疫苗加强免疫接种率分别是48.6%和50.2%;流动人口、计划外生育儿童建卡率、建证率仅为57.4%和74.4%,四苗接种率和乙肝疫苗接种率仅为42.6%和48.9%。
结论:①浏阳市乡镇卫生院的卫生资源相对较充足;浏阳市乡镇卫生院发展呈两极分化趋势,将影响到农村基本医疗和公共卫生服务的公平性与可及性;政府投入相对不足,使乡镇卫生院公共卫生服务弱化。②浏阳市村卫生室发展两极分化趋势明显;村卫生室服务功能简单,以药品销售为主;服务人员年龄老化、专业素质较差。③所调查的三个乡镇平均“四苗”接种率呈现逐年下降的趋势,而加强免疫接种率则整体偏低;乡镇级计免人员人手相对不足,导致接种半径过大,边远地点儿童的免疫得不到保障,影响乡镇计划免疫工作的有效开展;流动人口、计划外生育儿童是计划免疫接种的薄弱环节;“四苗”接种率与乡级计免人员配备情况、出生年份、出生地点、是否有预防接种卡四个因素有关。
第四篇浏阳市农村卫生服务调查的综合分析
1面临的形势与挑战:①慢性病成为了威胁浏阳农村居民健康最主要因素,农村居民患慢性病后所面临的经济负担十分繁重,而新型农村合作医疗杯水车薪,难以发挥抵御疾病风险的作用,导致患病后的卫生服务利用受到明显抑制。②乡镇卫生院是农民寻求卫生服务的最重要机构,在农村卫生服务网络中发挥着关键作用,但乡镇卫生院的建设与发展两极分化趋势明显,同时其农村公共卫生服务呈弱化趋势;村卫生室虽然是农民寻求卫生服务的主要场所之一,但由于卫生服务功能简单,且建设与发展很不平衡,难以发挥网底的作用;浏阳乡镇卫生院与村卫生室的现状不仅影响到农村卫生机构的公益性,而且影响到农村基本医疗服务和公共卫生服务的公平性与可及性。③浏阳农村已婚的育龄妇女生殖道感染率问题和妇科肿瘤问题不容忽视,健康知识与行为是农村妇女生殖道感染的主要影响因素,而生殖道炎症又是妇科肿瘤的重要危险因素,但浏阳市农村妇女妇科疾病的卫生服务利用率很低,农村妇女保健工作面临较大压力。④浏阳市农村卫生机构专业人才队伍建设不够合理,医疗、医技人员建设较好,而服务性公益性较强、经济效益较差的公共卫生与护理人员相对缺乏,难以满足农村卫生服务需求。
2政策性建议:①参照《农村卫生服务体系建设与发展规划》制定浏阳市乡镇卫生院和村卫生室建设标准,规范农村卫生机构的建设;加大政府对农村落后和偏远地区卫生院的投入,缩小卫生院之间的差距;加大对村卫生室服务人员的补充、培训与考评,确保农民公平享有基本医疗与公共卫生服务。②将乡镇卫生院服务功能社区卫生服务化,强化乡镇卫生院及临床医生的公共卫生服务功能;加大卫生院公共卫生服务经费投入与专职人员配备,提高计划免疫、疾病预防、妇幼保健水平,保证农村卫生服务的公益性。③将慢性病的预防控制与管理作为乡镇卫生院和乡村医生的最重要职责之一,提高农民整体健康水平和控制医疗费用增长。④大幅度提高新型农村合作医疗保险的标准,建议不低于城市居民的基本医疗保险标准保证农民在患病时能得到及时治疗,帮助农民抵御大病风险。⑤加大对高危人群和重点保健人群的周期性健康检查,做到早发现、早诊断、早治疗、早控制。
3本次研究成绩与不足:①通过对浏阳市农村居民主要健康问题、卫生服务需求评价、疾病经济负担、卫生服务利用调查、乡村两级卫生机构的卫生资源配置以及卫生服务开展情况的系统调查,基本明确了目前浏阳市农村医疗卫生工作中存在的主要问题和面临的压力,为浏阳市农村卫生发展规划提供了理论依据,对制订地方性的卫生政策具有一定的示范意义,但本次调查研究没有对农村医疗卫生服务质量进行深入研讨,也没有涉及农村精神卫生领域的调查,这都是我们今后需要进一步研究的重点。②在对浏阳市所有乡镇卫生院和村卫生室的公共卫生服务开展情况、经济收支情况、服务人员情况进行了综合调查的基础上,探索通过农村儿童基础免疫覆盖率的调查以及影响因素分析,来评价农村公共卫生服务核心工作的开展与落实情况,发现了目前农村公共卫生服务体系建设中存在的问题与不足,同时也为目前农村公共卫生工作滑坡的原因探索提供理论依据,还为评价农村公共卫生工作落实情况提供了重要的研究指标,但农村公共卫生服务的落实与效果评价需要更多的指标来综合反映。
Part 1 Research Background and significance
The rural health service plays an crucial role in improving the whole national health quality, protecting rural productive force, revitalizing the rural economy and maintaining the social development and national stability. Since the foundation of the People's Republic of China, the government departments have been greatly developing health services, establishing a broadly basic health organization and shaping a set of three-stage (country、township、village) public health net and rural health service teams which aim at the prevention, medical treatment and health care. The health level and life expectancy of rural dwellers have been improved greatly and continuously, and the incidence rate of infectious diseases, rural infant mortality and rural pregnant and puerpera mortality have declined markedly. However, the shortage of finance, the lack of health personnel and inferior infrastructure severely hampered the development of the rural pubic health system. With the speeding up of social aging process and the improving living standards, the comprehensive influence derived from environmental, psychological and social changes and chronic diseases has exerted a continually significant consequence in the health situation of rural dwellers and the medical economic burden has increased continuously, resulting in severe poverty of rural dwellers for illnesses.
At present, the main deficiencies existing in rural health services in China are as follows: (1) Insufficient funding of rural health services: the lack of government health funding resulted in not only the severe insufficiency of nationally rural health resources but also the continuous heavy burden of rural dwellers. (2) The shortage of professional and technical personnel for the rural sanitation and the maladjustment of rural health prevention and protection team with the need of health services: the rural health personnel resources are deficient, because the total number and technical capacities of personnel were low and the geographical distribution was uneven. Moreover, the elderly personnel working for health prevention and protection have relatively low technical capacity and lack professional training. (3) The weakening function of public health in townships hospitals: townships hospitals are the primary organization of rural public health work, the key point of the rural public health services system, and also an extraordinarily weak domain. On the one hand, the prevention and protection agencies are incomplete and the distribution of professional personnel are unequal. On the other, the fund appropriation for prevention and protection is so trivial that the public health services have enormous difficulty to carry out effectively and efficiently, bringing about the low function of prevention and protection services net throughout the rural areas. Moreover, driven by the locally economic benefits, the scope and standards of compensable health prevention and protection have varied and increased the burden of rural dwellers. (4) The poor accessibly and equity of rural health services: firstly, the medical sanitation institutions were deficient in remote areas. Secondly, the lack of governmental fund appropriation and benefits driven by the market economic conditions tremendously damaged the commonweal of public medical institutions. Finally, because of poor health awareness, rural dwellers failed to go to regular hospitals for examination and treatment when they are diseased. (5) The main problem of new rural cooperative medical systems: although these new rural cooperative medical systems have had relatively favorable achievements, the shortcomings were obvious. One is the cooperative medical fund had a relatively low standard and enormous difficulties to finance, and the other is the lack of the criterion of practical manipulation. The new rural cooperative medical system hardly sustain the disease burden of the sick rural dwellers, because of the limited percentage of reimbursement of medical expenses, they always abandoned the medical treatments.
Nowadays, the research priorities of health services overseas in rural and remote areas are as follows: (1) The cultivation, supplementation and stability of personnel resources for public health in rural and remote areas: facing the reality that the health system has unstable health team and lacks sufficient technical personnel, a great number of nations choose primary and effective methods as follows: firstly, they pay enormous attention to training the technical capacity of rural community doctors to improve their services. Secondly, they also could run medical colleges to cultivate professionals for rural areas or recruit rural-oriented medical students. Finally, they enroll those staffs who have experience in rural health services to receive training again in professional schools. (2) The utilization of health services in rural communities: the international experts find, when they investigate the relatively low utilization rate of health services in rural communities, that rural patients choose health services institutions depending on their subjective feel and judgments. Meanwhile, the situation about the equipment level, the operation condition, service capacity and scope would influence the medical preference of rural patients, especially those elderly patients. They also state that strengthening the construction and the cooperation of the network of rural health services between rural community hospitals and large medical centers is an extremely significant access to meet rural residents' demands for health services.
In China, there are many many studies about rural health service system, requirement and utilization of rural health service, rural health service professional team, rural public health service status, new type rural cooperative medical sysems, prevention and cure of rural areas infectious disease and chronic disease, service function orientation of township hospitals, health service status of village clinic. But, after the disease spectrum changed, and chronic disease had become the mostly health threaten, we lack of compositive and systemic study about health status with sanitation resource scheme. Our nation is still a huge agricultural one, whose rural dwellers accounts for 55% of the entire population, thus the health situation of rural residents is the biggest bread-and-butter issue. How to improve the public health services and basic medical services in rural areas and how to implement the primary health care for all the citizens, are the goal chased by all levels of government departments and health professional personnel. Ministry of Health has conducted three National Health Service survey, exerting an enormously positive influence in promoting national health reform and development, instituting the development plans for health enterprise, distributing health resources rationally, adjusting the supply and demand relationship of health services, and improving the health level of residents. However, China owning an extraordinarily vast territory, the economic development is unbalanced, the distribution of health resources is uneven, the people's level of education, living standards and health situations are extremely disparate. Therefore, investigating the situation about local residents' health and health services could help direct realistically how to institute development plans for local sanitary enterprise. Liuyang City is country-level city located in mountains of eastern Hunan Province, which was once an old revolutionary base. Although having active private economic and relatively fast economic development, Liuyang City has highlighted imbalances in development, which is to a certain degree representative in Hunan Province. From December 2006 to May 2007, we investigated the health condition, disease and economic burden and the utilization of health services of rural residents in Liuyang City. Then we generally studied medical institutions of all the townships to provide scientific evidences for instituting rural health policies that are applicable to social and economical development, further perfecting and promoting rural public health policies and works.
Part 2 The health survey of rural residents in Liuyang city
Objective: To explore chronic disease spectrum and economic burden of the rural residents, and understand the current situation about the two-week prevalence rate and the utilization of health services in rural areas , and understand the prevalence rate of gynecological tumor in rural areas and explore the common risk factors , and understand reproductive tract infections status of rural women and the main influential factors, in Liuyang City, Hunan Province.
Methods: (1)To determining the study objects using stratified cluster sampling ,they are Zhentou and Shankou and Yanghua villages and towns . we screened out the chronic diseases and selected a certain number of cases from 10 kinds of primary diseased randomly. Then we investigated their financial burden deeply, using methods that combined the questionnaire survey and medical inspection. (2)Using cross-sectional study, we surveyed the situation of injuring of past two weeks and of patients' searching for health services among more than 3200 rural residents in 3 villages distributed in 3 townships respectively, which involved Sankou, Yanghua and Zhentou. The content of the study involved social demography characters of family members, the severity of illness during the two weeks before the investigation, the situation about searching for health services, the options and reasons of choosing medical institutions and the reasons of failing to search. (3)Adopting the case-control study method, we investigated the menstrual history, marriage history, past history, family history of both 73 rural women cases acquired from communities and 140 control cases. After collecting the entire data, we made single-factor analysis and multivariate analysis. (4)As far as the general demography data, personal health habits, the utilization of the sanitary services and routine gynecological examination are concerned, we investigated some married women of childbearing age in 6 villages of 3 townships involving Zhentou, Sankou and Yanghua in Liuyang city using the systematic cluster sampling.
Results: (1)The chronic diseases prevalence rate of rural residents in Liuyang City reached 160.62‰. The top 10 chronic diseases involved hypertension, calculus in urinary system, rheumatoid arthritis, chronic bronchitis, chronic gastroenteritis, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes mellitus, cholecystitis and cholelithiasis. Among all these illnesses, the prevalence rates of hypertension, rheumatoid arthritis, chronic obstructive pulmonary disease, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes, cholecystitis and cholelithiasis in Liuyang City were higher than the average levels in rural areas throughout the nation in 2003. The economic burden situation of 10 main chronic diseases is as follows: the economic burden of hypertension in the highest, reaching 71.8071 million yuan, followed by calculus in urinary system (51.2963 million yuan), intervertebral disc disease (31.9046 million yuan), cerebrovascular disease (31,440,600 yuan ), chronic bronchitis (30.4576 million yuan), rheumatoid arthritis (29.332 million yuan), cholecystitis cholelithiasis (28.2804 million yuan), diabetes (27.9456 million yuan), coronary heart disease (27,418,800 yuan) and chronic gastroenteritis (22,878,700 yuan). The total economic burden of 10 kinds of chronic diseases discussed above in 2006 reached 353 million yuan, in other words, 296 yuan per capita, accounting for 6.4 percent of Liuyang expenditure per farmer who had consumed 4614 yuan in 2006. Each patient suffered from an average of 2,800 yuan as economic burden, which accounted for 60.7% consumption expenditure per capita, 4614 yuan. (2)The prevalence rate of two-week rural residents in Liuyang City was 152.3%, which was slightly higher than 139.5%, the two-week prevalence rate reported by the national health survey in 2003. Among all the illness investigated, the chronic diseases, which continued for two weeks accounted for 74.8%, About 51.6% patients would choose to search for treatments and 64.4% of them would go to the second-stage health institutions, such as township hospitals and village clinics. The main reasons that rural patients failed to see doctors involved feeling their diseases slight by self-inductance, economic difficulty and non-effective measures, which accounted for 52.9%, 26.0% and 16.5% respectively. (3) The prevalence rate of gynecological tumor of rural women above 20-year-old was 4.7523 per thousand, among them the prevalence rate of malignant tumor was 1.6897 per thousand. The results of single factor analysis were as follows: the common gynecological tumor-related risk factors of rural women were dysmenorrheal, menopause, the use of postmenopausal hormone drugs, breast-feeding, contraceptive pill, gynecological inflammation, history of suffering from other chronic diseases and family history of cancer; the protective factor was pregnancy. The results of multivariate analysis showed that the common risk factors of gynecological tumor incidence of rural women were contraceptive use [OR=20.614, 95.0%CI (1.301 - 326.623) ] and gynecological inflammation [OR=31.635, 95.0%CI (1.836-544.966)] . (4) According to our investigation, 41.4% rural women in Liuyang city suffered reproductive tract infections, including chronic cervicitis and vaginitis, which were 68.3% and 31.1% respectively. The rural women who were 35 - 50-year-old had the highest reproductive tract infections rate 45.6%. The women who did occasional cleaning or non-cleaning had 1.59 times more risk in suffering the reproductive tract infections than those who did cleaning frequently and continually. Only 18.9% rural women wanted to go to hospital for treatment after they found they had reproductive tract infections symptoms.
Conclusion: (1)In 2006, the prevalence rate of chronic diseases of rural residents in Liuyang City is higher than that of the national rural residents in 2003 and the chronic diseases spectrum was similar to that of national rural residents. The 10 kinds of major chronic diseases exerted an extraordinarily significant and financial influence on the patients in rural areas in Liuyang City. (2) The chronic diseases took an extremely crucial role in threatening the health of the rural residents; the distance was the primary influential factor in choosing medical institutions; rural patients always abandon the treatment for several reasons, such as little consciousness of maintaining health, the economic burden of seeing doctors and the financial difficulties of curing chronic illnesses. (3) Suffering from gynecological inflammation were common risk factors of gynecological tumor. (4) The reproductive tract infections rate in Liuyang City was closed to the results of other domestic relevant surveys; the major and high-risk population to prevent reproductive tract infections was 35-50-year-old married women in rural areas; lacking personal health knowledge and positive sexual health habits played an exceedingly vital role in reproductive tract infections of rural women; the utilization rate of health services was low after the rural women suffered reproductive tract infections; the census and treatment policies conducted by Liuyang MCH hospital in the past ten years were still crucial and effective to improve the health status of reproductive tract infections of rural women.
Part 3 The survey of current status of rural health services of Township Hospitals and Village Clinics in Liuyang City
Objective: To investigate the present situations of sanitation resources and health service of township hospitals and Village Clinics in Liuyang City and to provide evidences for development of township hospitals and Village Clinics; To explore the current status about the child immunization and to provide evidences for evaluating the rural public health in rural areas of Liuyang.
Methods: The study was conducted by a general investigation to 36 township hospitals and 687 village clinics, concerning the infrastructure, health professionals, primary care, public health service and income / expenses. We surveyed the situation about the basic and strengthening immunization among 630 children, who were born between January 1, 2003 to December 31, 2005 in 3 townships involved Zhentou, Sankou and Yanghua. Then we made qualitative investigations about the professional training of planned immunization, vaccination management and data archiving.
Results: (1) The average coverage of these medical institutions was 36,790 persons, which means 1.5 professionals per thousand residents; the professionals working in the medical institutions of countries and townships accounted for 88% of the total staffs; the average person of public health personnel was 3.8 persons per hospital. In 2005 the sickbed utilization mean ratio was 58.9% and 184,639 patients received diagnosis and treatments per year. 2/3 income of township hospitals derived from vaccination in the recent five years. The maximum of personnel, sickbeds, operation areas and capital asserts were 196 person, 170 person, 10900 m~2 and 21.46 million yuan respectively. Oppositely the minimum of them were 7 person, 6 person, 400m~2 and 0.41 million yuan. (2) According to the investigation, there were 1,158 health professionals and 757 village doctors totally, which meant 0.89 health personnel and 0.58 village doctors were working for thousand residents. The village doctors who were over fifty years old accounted for 52.3%, and who lacked professional training accounted for 54.8%. The operation areas of village hospitals varied from 200m~2 to 1m~2, and 36.7% of them were lower than 45m~2. The capital asserts fluctuated from 1.5 million yuan to 10 thousand yuan. 76.8% of the entire income of village clinics rooted in the sales amount of medicines. The main public health services of village clinics included reporting epidemic situation, health education, informing vaccination and reporting birth and death and so on. (3) Three villages had 5 professionals serving rural dwellers according to the planned immunization program of a total population of 98,383 residents and the professionals ratio was 51 personnel per million citizens; among 3 age groups the average ratio of running the cards and certifications was 90.5% and 86.7% respectively. 75.06% of children in 3 age groups had full basic immunization, which involved Bacilli Calmette Guerin (BCG) vaccination 91.52%, Oral Polio Vaccine (OPV) 86.49%, Diphtheria Pertussis Tetanus (DPT) 83.91%, Measles Vaccines (MV) 81.08%. The rate that children accepted all the four vaccination was 79.35% in 2003, 76.74% in 2004 and 69.53% in 2005; the hepatitis B vaccination coverage rate was 84.3% and the coverage rate of strengthening immunization of DTP and MV were 48.6% and 50.2% among children all the three age groups; the running rate of card and certification of the floating population and the children who were born against one-child policy were only 57.4% and 74.4% and the four vaccination rate and hepatitis B vaccination rate of them were 42.6% and 48.9% respectively.
Conclusions: (1)The health resources of township hospitals are relative enough in Liuyang City; The developing trend of Liuyang township hospitals reveals polarization, which has affected the fairness and the availability of countryside primary care and public health service; The government investment is relative insufficient, which weakens the capability of public health service of township hospitals. (2)The obviously bipolar trend of medical hospitals in villages in Liuyang City would influence the equity and accessibility of rural basic diagnosis and treatments and public health services; The main function of village clinics were simply, mainly depending on the sales of medicine. The health personnel were elderly and lacked professional training. (3) In three townships investigated, the four vaccination rate showed a downward trend year by year, while strengthening vaccination rate was low in general; the townships workstations had a relative shortage of professionals, which led to the fact that the vaccination coverage radius was so large that the vaccinations of children in remote areas were not protected by the immune effects of the township planned immunization; the floating population and the children born against one-child policy were the weak points of the plan; the four vaccination rate was relevant to four factors, such as the professionals engaging in the vaccination enterprise, year of birth, place of birth and having vaccination card.
Part 4 The comprehensive analysis of rural health services investigation in Liuyang
1) Situation and challenges faced: (1)Chronic diseases had become the most essential factor threatening rural residents' health status. So heaviest burden was the economic burden after the rural patients suffered chronic diseases, and new rural cooperative institutions hardly help rural dwellers resist the risk of diseases. the utilization of health services was significantly restrained. (2) township hospitals are the main healthcare institution that rural residents utilize health service, the insufficient funding appropriation of rural health resulted in continuously tremendously bipolar trend between the formation and development of health institutions in countries and that in villages. Meanwhile, the weakness of rural public health services would significantly influence the public welfare of rural health institutions and the equity and accessibility of rural basic medical services and public health services.(3) The reproductive tract infections rate of married women in reproductive age and the incidence rate of both benign and malignant cancer of rural women are more important problem in Liuyang City. The health knowledge and behaviors were the main influential factors and the reproductive tract inflammation was the significant risk factor. But the utilization rate of health services of rural women's gynecopathy in Liuyang City was so low that the health prevention and protection of rural women suffered tremendous pressure. (4) The formation of professional team in rural sanitary organizations in Liuyang City failed to be reasonable. The staffs for medical treatments were sufficient, but the personnel working for public health and nursing care, who had higher commonweal and lower economic benefits, were relatively deficient to meet the standards of rural health services.
2) Policies recommended: (1) According to "rural health service system formation and development planning", we could institute the construction standards of medical institutions in countries and townships and standardize the establishment of rural sanitary organizations; we could increase the fund that government appropriated to the hospitals in rural and remote areas and decline the gap between the medical institutions in countries and that in villages; we could enlarge the supplement, training and evaluation of service personnel in village stations and ensure all the rural dwellers could share fairly basic medical treatments and public health services. (2)We could transform the mode of medical institutions in countries and townships to the style of community health services, and strengthen the public health services functions of medical institutions and clinical doctors in countries and villages. We could also enlarge the fund appropriation for public health services and the total number of professionals and increase the level of planned immunization, disease prevention and women and children health care, it can enhance the commonweal of rural health service. (3) The most primary responsibilities as the doctors in medical institutions of countries and townships was to control and govern the prevention and medial expenses of chronic diseases and to increase the health level of rural dwellers. (4) It is recommended that the insurance standards of new rural cooperative institutions should not be lower than that of townsmen,. Make sure the rural dwellers can receive beneficial treatments in time, which would help farmers resist the risk of serious illness. (5) We could increase focus on the cyclical health examinations of high-risk and crucial population to ensure early discovery, diagnosis, treatment and control.
3) Discuss of research achievement and deficiency: (1) Through the systematic survey of the main health problem of rural dwellers, the need assessment and the utilization of health services, the financial burden of diseases, the health resources allocation and situation of medical institutions in countries and townships, we could basically understand the current problem and pressure existing in the rural medical enterprise in Liuyang City, to provide a theoretical evidence for the rural health development plans and the establishment of the local health policies. However, the present investigation did not involve the quality of rural medical health services and the situations about rural mental health, which are the focus of further study. (2) On the basis of the comprehensive survey of public health services, the economic balance and the professionals, we surveyed the basic immunization coverage rate and its influential factors about rural children, to evaluate the development and implementation of the core work of public health services. Through the study, we found several deficiencies in the current rural public health services system and provided the theoretical references for the reasons of the deterioration of the rural public health care and the direction of further implements, but the evaluation of the implementation and effectiveness of the rural public health services needs more comprehensive indexes to be reflected correctly and precisely.
农村卫生工作是关系到提高全民族素质、保障农村生产力、振兴农村经济、维护农村社会发展和稳定的重要工作。新中国成立后,政府大力发展卫生事业,广泛建立了基层卫生体系,形成了集预防、医疗、保健于一体的农村三级(县、乡、村)公共卫生服务网络和农村卫生队伍。农民健康水平得到较大提高,传染病发病率、婴幼儿死亡率、孕产妇死亡率明显下降,期望寿命不断提高。但是农村卫生工作仍面临着资金投入不足、卫生人才匮乏、基础设施落后的问题。随着人口老龄化进程加快,生活水平的提高,环境、心理、社会等的综合影响,慢性病对农民健康的影响越来越突出,医疗费用负担不断增加,农民因病致贫、返贫问题仍然突出。
目前我国农村卫生服务存在的主要问题:①经费投入不足:政府卫生经费投入不足,不仅导致了我国农村卫生资源的严重不足,而且导致农村居民的医疗卫生负担越来越重。②农村卫生专业技术队伍缺乏:农村卫生人力资源不足一是人员总数量上不足,二是专业技术水平低,三是在地区分布上不均衡;同时农村预防保健人员业务素质偏低,缺乏专业培训,年龄结构偏大难以适应卫生服务需求。③乡镇卫生院公共卫生服务功能弱化:乡镇卫生院是承担乡镇公共卫生工作的主要机构,是农村公共卫生服务体系的关键环节,也是目前非常薄弱的环节,一方面是预防保健机构不健全、人员配备不到位;另一方面是预防保健费用不足,公共卫生服务难以开展,导致整个农村预防保健服务网功能低下,同时因受经济利益驱使,扩大了预防保健有偿服务范围和标准,从而加重了人民群众的负担。④农村卫生服务的可及性与均衡性差:农村偏远地区医疗卫生机构的缺失是农村卫生服务可及性差的最主要原因;政府投入不足、市场经济条件下利益驱动等因素导致公立医疗机构的公益性几乎消失,是农村卫生服务不均衡的重要原因;而农民健康意识不强,有了病也不先去正规医院检查治疗,成为农村卫生服务不均衡和可及性差的另一潜在因素。⑤新型农村合作医疗虽已取得较好的效果,但也存在合作医疗基金筹集困难且标准偏低和实际操作缺乏规范的问题。大多数患者由于能报销医疗费用的比例有限而放弃治疗,新农合并未起到抵御疾病风险的作用。
国外对农村及偏远地区的卫生服务问题研究重点:①农村偏远地区卫生人力资源的培养、补充和稳定:面临农村卫生队伍不稳、技术人员缺乏的现实,很多国家采取的最主要也是最有效的手段是:重视开展农村社区医生的技能培训,提高服务能力;在农村办医学院校或由医学院从农村定向招收医学生为农村培养人才,或增加有农村卫生服务经历的人员来学校接受培训的办法。②农村社区的医疗卫生服务利用:国际专家在研究农村社区的医疗卫生服务利用率不高问题时发现,农村居民患者对卫生服务机构的选择与其主观感受和判断有很大关系,农村地区医院的设备水平、经营状况、服务能力与范围等都会影响农村病人特别是老年患者的医疗保健;并提出加强农村卫生服务网络建设,加强农村社区医院与大型医疗中心的合作,是满足农村居民卫生服务需求的重要途径。
国内针对有关农村卫生服务体系建设、农村卫生服务需求与利用、农村卫生人才队伍建设、农村公共卫生现状、新型农村合作医疗、农村传染病与慢性病的防治、乡镇卫生院服务功能定位、村卫生室服务现状的研究较多。但是在疾病谱发生改变、慢性病已成为威胁农民健康的最主要因素后,没有针对地区居民健康状况与当地卫生资源配置以及卫生服务开展情况的综合的、系统的研究,尤其缺乏对乡(镇)、村两级卫生机构的系统研究。我国仍是一个农业大国,农业人口占全国人口的2/3,农村居民的健康问题是最大的民生问题,如何发展农村公共卫生服务与基本医疗服务,实现人人享有基本医疗卫生服务,是各级政府和广大卫生工作者努力追求的目标。卫生部先后三次开展国家卫生服务调查,对于促进我国卫生改革与发展,制定卫生事业发展规划,合理配置卫生资源,提高居民健康水平产生了积极影响。但由于我国幅员辽阔,各地区间的经济发展不平衡,卫生资源分布很不均衡,人们的文化水平、生活水平、健康水平等均不尽相同,各地方仍需参照国家卫生事业发展规划,并根据各地的现状与卫生服务需求制订相应的卫生发展规划。因此,开展地方性的居民健康状况和卫生服务调查对制定地方性卫生事业发展规划具有现实指导意义。浏阳市是湖南省地处湘东的山区革命老区县级市,民营经济活跃,经济发展较快;除血吸虫病外其它的各种传染病、地方病、慢性病等健康问题、居民生活水平与习惯、人口构成等与全省相似,而卫生资源配置与卫生服务水平也接近全省平均水平,在湖南省具有较好的代表性。我们于2006年12月-2007年5月对浏阳市农村居民进行了健康状况、疾病经济负担以及卫生服务利用调查,并对全市所有乡镇卫生院和村卫生室进行普查,为制定符合浏阳市社会经济发展的农村卫生政策提供依据,为进一步完善湖南省农村公共卫生政策、促进农村公共卫生工作提供参考。
第二篇浏阳市农村居民健康调查
目的:研究浏阳市农村居民慢性病的疾病谱及主要慢性病经济负担,农村居民两周患病率及卫生服务利用现况;农村妇女生殖道感染状况和主要影响因素,农村妇女妇科肿瘤的危险因素。
方法:采用分层整群抽样的方法确定浏阳镇头镇、三口乡和杨花乡(代表经济好、中、差)为研究对象,首先进行慢性病筛查,然后从筛查出的10种主要慢性病中随机抽样选取一定数量的病例进行慢性病经济负担的深入调查,调查方式为问卷调查和病历查阅相结合;采用整群抽样方法对3个乡镇的3个村3200余名农村居民进行两周内伤病情况及寻求卫生服务情况调查,内容包括家庭成员的社会人口学特征,居民在调查的前两周内患病情况,以及因患病而寻求卫生服务情况,就诊机构的选择及其原因,未就诊的原因等;采用病例对照的研究方法,对73名筛查获得的农村妇科肿瘤病例和140例对照进行有关月经史、婚育史、既往史、家族史等因素的调查分析,对所得资料进行单因素分析和多因素分析;采用系统整群抽样方法对3个乡镇各抽取2个共6个村的已婚的育龄妇女进行普查,内容包括一般人口学资料和个人卫生习惯,卫生服务利用情况以及常规妇科检查。
结果:①浏阳农村居民慢性病患病率达到160.62‰,慢性病前10位的疾病为高血压、泌尿系统结石症、类风湿关节炎、慢性支气管炎、慢性胃肠炎、冠心病、椎间盘疾病、脑血管疾病、糖尿病、胆囊炎及胆石症;高血压、类风湿关节炎、慢性阻塞肺病、冠心病、椎间盘疾病、脑血管疾病、糖尿病、胆囊炎及胆石症的患病率均高于2003年全国农村平均水平;全市10种主要慢性病的经济负担分别为:高血压病的经济负担最高,达到7180.71万元,其次分别为泌尿系统结石(5129.63万元)、椎间盘疾病(3190.46万元)、脑血管疾病(3144.06万元)、慢性支气管炎(3045.76万元)、类风湿关节炎(2933.20万元)、胆囊炎胆石症(2828.04万元)、糖尿病(2794.56万元)、冠心病(2741.88万元)和慢性胃肠炎(2287.87万元)。以上10种慢性病2006年全市的总经济负担合计达到3.53亿元,人均负担达到296元,占年浏阳2006年农民人均消费性支出4614元的6.4%。每名患者的平均经济负担为2800元,占人均消费性支出4614元的60.7%。②浏阳农村居民两周患病率为152.3‰,略高于国家2003年卫生调查结果农村居民两周患病率139.5%o,其中慢性病持续到两周内的占74.8%;农村居民两周内患病后,有51.6%的患者到医院就诊,其中到村卫生室和乡镇卫生院两级卫生机构所占比例达到64.4%;患者未就诊的主要原因是自感病轻占52.9%、经济困难占26.0%和无有效措施占16.5%。③单因素分析结果发现:农村妇女妇科肿瘤有关的共同危险因素为月经期有痛经、已绝经、绝经后服用激素类药物、哺乳、服用避孕药避孕、患有妇科炎症、患有其他慢性疾病史;多因素分析显示:服用避孕药(OR=11.800,95.0%C.I(1.870～74.476)、患有妇科炎症(OR=11.800,95.0%C.I(2.245～62.032)是农村妇女妇科肿瘤发病的独立的危险因素。④浏阳市农村妇女生殖道感染率为41.4%,疾病构成以慢性宫颈炎和阴道炎为主,分别占了68.3%和31.1%;35～50岁组的生殖道感染率最高,为45.6%;偶尔或不清洗患生殖道感染的危险是经常洗的1.59倍;农村妇女出现生殖道感染症状后,仅18.9%到医院就诊;
结论:①浏阳农村居民慢性病患病率高于全国2003年农村居民慢性病患病率;慢性病谱与全国农村居民慢性病谱近似;浏阳农村10种主要慢性病给患者带来较大的经济负担。②慢性病成为农村居民的最主要的健康威胁;距离近成为其选择就诊单位时首要影响因素;农村患者因健康维护意识不强、看病贵经济压力大、慢性病难治愈等原因而放弃医治。③反复妇女生殖道感染是妇科肿瘤共同的危险因素。④浏阳市农村妇女生殖道感染率与国内相关调查结果接近;农村妇女生殖道感染防治的重点人群和高危人群是35-50岁已婚妇女;缺乏个人卫生知识和良好的性卫生习惯是农村妇女生殖道感染的主要影响因素:农村妇女出现生殖道感染症状后卫生服务利用率偏低;浏阳妇幼保健院近十多年来的普查普治政策仍将是提高农村妇女生殖健康的有效措施之一。
第三篇浏阳市乡镇卫生院和村卫生室卫生服务现状调查
目的:通过对浏阳市乡镇卫生院和村卫生室基本建设情况与业务开展情况调查,为促进乡镇卫生院和村卫生室发展提供依据:了解浏阳农村当前儿童免疫规划工作现状,为评价浏阳农村公共卫生工作落实情况提供依据。
方法:对浏阳市36所乡镇卫生院的基本情况、卫生技术人员情况、基本医疗和公共卫生服务开展情况、近五年经费收入支出情况等进行全面调查;对浏阳市687所村卫生室进行普查,主要内容包括村卫生室基本情况、收支情况、农村公共卫生工作开展情况等;对镇头、三口、杨花三个乡镇从2003年1月1日至2005年12月31日出生的儿童共计630名儿童进行基础免疫和加强免疫接种情况的调查,并对计划免疫专业队伍建设、接种管理与资料建档等进行定性调查。
结果:①浏阳市36所乡镇卫生院平均服务人口为36790人,平均每千服务人口的卫生技术人员1.5人;乡镇卫生院的卫生技术人员占职工总数比例88%;公共卫生服务人员院均值为3.8人;36所乡镇卫生院2005年的病床使用率为平均58.9%,年均诊疗18463.9人次;近5年来,乡镇卫生院公共卫生收入的2/3来源于预防接种:乡镇卫生院职工最多196人,最少仅7人,病床最多170张,最少的仅6张,业务用房面积多的10900m~2,少的仅400m~2,固定资产最多的2146万元,最少仅41万元。;②687所村卫生室共有卫生服务人员1158人、村医757人,每千服务人口有村卫生服务人员0.89人、村医0.58人,50岁以上村医占52.3%,无专业学历的的卫生服务人员占54.8%;36.7%的村卫生室业务用房面积低于45m~2,业务用房面积最大的有200 m~2,最小的只有1 m~2,相差200倍;固定资产最大值为150.0万元,最小为0.1万元,相差1500倍;687所村卫生室的药品收入占总收入的76.8%;村卫生室公共卫生工作主要是疫情报告、健康教育、接种通知、出生与死亡上报等工作。③三个乡共有计划免疫专职人员5人,总服务人口98383人,计划免疫专职人员平均配置比例0.51/万人;三个年龄组的平均建卡率为90.5%,平均建证率为86.7%;三个年龄组儿童的“四苗”基础免疫全程接种率为75.06%,其中卡介苗(BCG)接种率91.52%,脊灰疫苗(OPV)接种率86.49%,百白破(DPT)接种率83.91%,麻疹疫苗(MV)接种率81.08%。儿童“四苗”基础免疫全程接种率2003—2005年分别为79.35%、76.74%、69.53%;三年龄组乙肝疫苗全程接种率84.3%;三年龄组的平均儿童百白破和麻疹疫苗加强免疫接种率分别是48.6%和50.2%;流动人口、计划外生育儿童建卡率、建证率仅为57.4%和74.4%,四苗接种率和乙肝疫苗接种率仅为42.6%和48.9%。
结论:①浏阳市乡镇卫生院的卫生资源相对较充足;浏阳市乡镇卫生院发展呈两极分化趋势,将影响到农村基本医疗和公共卫生服务的公平性与可及性;政府投入相对不足,使乡镇卫生院公共卫生服务弱化。②浏阳市村卫生室发展两极分化趋势明显;村卫生室服务功能简单,以药品销售为主;服务人员年龄老化、专业素质较差。③所调查的三个乡镇平均“四苗”接种率呈现逐年下降的趋势,而加强免疫接种率则整体偏低;乡镇级计免人员人手相对不足,导致接种半径过大,边远地点儿童的免疫得不到保障,影响乡镇计划免疫工作的有效开展;流动人口、计划外生育儿童是计划免疫接种的薄弱环节;“四苗”接种率与乡级计免人员配备情况、出生年份、出生地点、是否有预防接种卡四个因素有关。
第四篇浏阳市农村卫生服务调查的综合分析
1面临的形势与挑战:①慢性病成为了威胁浏阳农村居民健康最主要因素,农村居民患慢性病后所面临的经济负担十分繁重,而新型农村合作医疗杯水车薪,难以发挥抵御疾病风险的作用,导致患病后的卫生服务利用受到明显抑制。②乡镇卫生院是农民寻求卫生服务的最重要机构,在农村卫生服务网络中发挥着关键作用,但乡镇卫生院的建设与发展两极分化趋势明显,同时其农村公共卫生服务呈弱化趋势;村卫生室虽然是农民寻求卫生服务的主要场所之一,但由于卫生服务功能简单,且建设与发展很不平衡,难以发挥网底的作用;浏阳乡镇卫生院与村卫生室的现状不仅影响到农村卫生机构的公益性,而且影响到农村基本医疗服务和公共卫生服务的公平性与可及性。③浏阳农村已婚的育龄妇女生殖道感染率问题和妇科肿瘤问题不容忽视,健康知识与行为是农村妇女生殖道感染的主要影响因素,而生殖道炎症又是妇科肿瘤的重要危险因素,但浏阳市农村妇女妇科疾病的卫生服务利用率很低,农村妇女保健工作面临较大压力。④浏阳市农村卫生机构专业人才队伍建设不够合理,医疗、医技人员建设较好,而服务性公益性较强、经济效益较差的公共卫生与护理人员相对缺乏,难以满足农村卫生服务需求。
2政策性建议:①参照《农村卫生服务体系建设与发展规划》制定浏阳市乡镇卫生院和村卫生室建设标准,规范农村卫生机构的建设;加大政府对农村落后和偏远地区卫生院的投入,缩小卫生院之间的差距;加大对村卫生室服务人员的补充、培训与考评,确保农民公平享有基本医疗与公共卫生服务。②将乡镇卫生院服务功能社区卫生服务化,强化乡镇卫生院及临床医生的公共卫生服务功能;加大卫生院公共卫生服务经费投入与专职人员配备,提高计划免疫、疾病预防、妇幼保健水平,保证农村卫生服务的公益性。③将慢性病的预防控制与管理作为乡镇卫生院和乡村医生的最重要职责之一,提高农民整体健康水平和控制医疗费用增长。④大幅度提高新型农村合作医疗保险的标准,建议不低于城市居民的基本医疗保险标准保证农民在患病时能得到及时治疗,帮助农民抵御大病风险。⑤加大对高危人群和重点保健人群的周期性健康检查,做到早发现、早诊断、早治疗、早控制。
3本次研究成绩与不足:①通过对浏阳市农村居民主要健康问题、卫生服务需求评价、疾病经济负担、卫生服务利用调查、乡村两级卫生机构的卫生资源配置以及卫生服务开展情况的系统调查,基本明确了目前浏阳市农村医疗卫生工作中存在的主要问题和面临的压力,为浏阳市农村卫生发展规划提供了理论依据,对制订地方性的卫生政策具有一定的示范意义,但本次调查研究没有对农村医疗卫生服务质量进行深入研讨,也没有涉及农村精神卫生领域的调查,这都是我们今后需要进一步研究的重点。②在对浏阳市所有乡镇卫生院和村卫生室的公共卫生服务开展情况、经济收支情况、服务人员情况进行了综合调查的基础上,探索通过农村儿童基础免疫覆盖率的调查以及影响因素分析,来评价农村公共卫生服务核心工作的开展与落实情况,发现了目前农村公共卫生服务体系建设中存在的问题与不足,同时也为目前农村公共卫生工作滑坡的原因探索提供理论依据,还为评价农村公共卫生工作落实情况提供了重要的研究指标,但农村公共卫生服务的落实与效果评价需要更多的指标来综合反映。
Part 1 Research Background and significance
The rural health service plays an crucial role in improving the whole national health quality, protecting rural productive force, revitalizing the rural economy and maintaining the social development and national stability. Since the foundation of the People's Republic of China, the government departments have been greatly developing health services, establishing a broadly basic health organization and shaping a set of three-stage (country、township、village) public health net and rural health service teams which aim at the prevention, medical treatment and health care. The health level and life expectancy of rural dwellers have been improved greatly and continuously, and the incidence rate of infectious diseases, rural infant mortality and rural pregnant and puerpera mortality have declined markedly. However, the shortage of finance, the lack of health personnel and inferior infrastructure severely hampered the development of the rural pubic health system. With the speeding up of social aging process and the improving living standards, the comprehensive influence derived from environmental, psychological and social changes and chronic diseases has exerted a continually significant consequence in the health situation of rural dwellers and the medical economic burden has increased continuously, resulting in severe poverty of rural dwellers for illnesses.
At present, the main deficiencies existing in rural health services in China are as follows: (1) Insufficient funding of rural health services: the lack of government health funding resulted in not only the severe insufficiency of nationally rural health resources but also the continuous heavy burden of rural dwellers. (2) The shortage of professional and technical personnel for the rural sanitation and the maladjustment of rural health prevention and protection team with the need of health services: the rural health personnel resources are deficient, because the total number and technical capacities of personnel were low and the geographical distribution was uneven. Moreover, the elderly personnel working for health prevention and protection have relatively low technical capacity and lack professional training. (3) The weakening function of public health in townships hospitals: townships hospitals are the primary organization of rural public health work, the key point of the rural public health services system, and also an extraordinarily weak domain. On the one hand, the prevention and protection agencies are incomplete and the distribution of professional personnel are unequal. On the other, the fund appropriation for prevention and protection is so trivial that the public health services have enormous difficulty to carry out effectively and efficiently, bringing about the low function of prevention and protection services net throughout the rural areas. Moreover, driven by the locally economic benefits, the scope and standards of compensable health prevention and protection have varied and increased the burden of rural dwellers. (4) The poor accessibly and equity of rural health services: firstly, the medical sanitation institutions were deficient in remote areas. Secondly, the lack of governmental fund appropriation and benefits driven by the market economic conditions tremendously damaged the commonweal of public medical institutions. Finally, because of poor health awareness, rural dwellers failed to go to regular hospitals for examination and treatment when they are diseased. (5) The main problem of new rural cooperative medical systems: although these new rural cooperative medical systems have had relatively favorable achievements, the shortcomings were obvious. One is the cooperative medical fund had a relatively low standard and enormous difficulties to finance, and the other is the lack of the criterion of practical manipulation. The new rural cooperative medical system hardly sustain the disease burden of the sick rural dwellers, because of the limited percentage of reimbursement of medical expenses, they always abandoned the medical treatments.
Nowadays, the research priorities of health services overseas in rural and remote areas are as follows: (1) The cultivation, supplementation and stability of personnel resources for public health in rural and remote areas: facing the reality that the health system has unstable health team and lacks sufficient technical personnel, a great number of nations choose primary and effective methods as follows: firstly, they pay enormous attention to training the technical capacity of rural community doctors to improve their services. Secondly, they also could run medical colleges to cultivate professionals for rural areas or recruit rural-oriented medical students. Finally, they enroll those staffs who have experience in rural health services to receive training again in professional schools. (2) The utilization of health services in rural communities: the international experts find, when they investigate the relatively low utilization rate of health services in rural communities, that rural patients choose health services institutions depending on their subjective feel and judgments. Meanwhile, the situation about the equipment level, the operation condition, service capacity and scope would influence the medical preference of rural patients, especially those elderly patients. They also state that strengthening the construction and the cooperation of the network of rural health services between rural community hospitals and large medical centers is an extremely significant access to meet rural residents' demands for health services.
In China, there are many many studies about rural health service system, requirement and utilization of rural health service, rural health service professional team, rural public health service status, new type rural cooperative medical sysems, prevention and cure of rural areas infectious disease and chronic disease, service function orientation of township hospitals, health service status of village clinic. But, after the disease spectrum changed, and chronic disease had become the mostly health threaten, we lack of compositive and systemic study about health status with sanitation resource scheme. Our nation is still a huge agricultural one, whose rural dwellers accounts for 55% of the entire population, thus the health situation of rural residents is the biggest bread-and-butter issue. How to improve the public health services and basic medical services in rural areas and how to implement the primary health care for all the citizens, are the goal chased by all levels of government departments and health professional personnel. Ministry of Health has conducted three National Health Service survey, exerting an enormously positive influence in promoting national health reform and development, instituting the development plans for health enterprise, distributing health resources rationally, adjusting the supply and demand relationship of health services, and improving the health level of residents. However, China owning an extraordinarily vast territory, the economic development is unbalanced, the distribution of health resources is uneven, the people's level of education, living standards and health situations are extremely disparate. Therefore, investigating the situation about local residents' health and health services could help direct realistically how to institute development plans for local sanitary enterprise. Liuyang City is country-level city located in mountains of eastern Hunan Province, which was once an old revolutionary base. Although having active private economic and relatively fast economic development, Liuyang City has highlighted imbalances in development, which is to a certain degree representative in Hunan Province. From December 2006 to May 2007, we investigated the health condition, disease and economic burden and the utilization of health services of rural residents in Liuyang City. Then we generally studied medical institutions of all the townships to provide scientific evidences for instituting rural health policies that are applicable to social and economical development, further perfecting and promoting rural public health policies and works.
Part 2 The health survey of rural residents in Liuyang city
Objective: To explore chronic disease spectrum and economic burden of the rural residents, and understand the current situation about the two-week prevalence rate and the utilization of health services in rural areas , and understand the prevalence rate of gynecological tumor in rural areas and explore the common risk factors , and understand reproductive tract infections status of rural women and the main influential factors, in Liuyang City, Hunan Province.
Methods: (1)To determining the study objects using stratified cluster sampling ,they are Zhentou and Shankou and Yanghua villages and towns . we screened out the chronic diseases and selected a certain number of cases from 10 kinds of primary diseased randomly. Then we investigated their financial burden deeply, using methods that combined the questionnaire survey and medical inspection. (2)Using cross-sectional study, we surveyed the situation of injuring of past two weeks and of patients' searching for health services among more than 3200 rural residents in 3 villages distributed in 3 townships respectively, which involved Sankou, Yanghua and Zhentou. The content of the study involved social demography characters of family members, the severity of illness during the two weeks before the investigation, the situation about searching for health services, the options and reasons of choosing medical institutions and the reasons of failing to search. (3)Adopting the case-control study method, we investigated the menstrual history, marriage history, past history, family history of both 73 rural women cases acquired from communities and 140 control cases. After collecting the entire data, we made single-factor analysis and multivariate analysis. (4)As far as the general demography data, personal health habits, the utilization of the sanitary services and routine gynecological examination are concerned, we investigated some married women of childbearing age in 6 villages of 3 townships involving Zhentou, Sankou and Yanghua in Liuyang city using the systematic cluster sampling.
Results: (1)The chronic diseases prevalence rate of rural residents in Liuyang City reached 160.62‰. The top 10 chronic diseases involved hypertension, calculus in urinary system, rheumatoid arthritis, chronic bronchitis, chronic gastroenteritis, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes mellitus, cholecystitis and cholelithiasis. Among all these illnesses, the prevalence rates of hypertension, rheumatoid arthritis, chronic obstructive pulmonary disease, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes, cholecystitis and cholelithiasis in Liuyang City were higher than the average levels in rural areas throughout the nation in 2003. The economic burden situation of 10 main chronic diseases is as follows: the economic burden of hypertension in the highest, reaching 71.8071 million yuan, followed by calculus in urinary system (51.2963 million yuan), intervertebral disc disease (31.9046 million yuan), cerebrovascular disease (31,440,600 yuan ), chronic bronchitis (30.4576 million yuan), rheumatoid arthritis (29.332 million yuan), cholecystitis cholelithiasis (28.2804 million yuan), diabetes (27.9456 million yuan), coronary heart disease (27,418,800 yuan) and chronic gastroenteritis (22,878,700 yuan). The total economic burden of 10 kinds of chronic diseases discussed above in 2006 reached 353 million yuan, in other words, 296 yuan per capita, accounting for 6.4 percent of Liuyang expenditure per farmer who had consumed 4614 yuan in 2006. Each patient suffered from an average of 2,800 yuan as economic burden, which accounted for 60.7% consumption expenditure per capita, 4614 yuan. (2)The prevalence rate of two-week rural residents in Liuyang City was 152.3%, which was slightly higher than 139.5%, the two-week prevalence rate reported by the national health survey in 2003. Among all the illness investigated, the chronic diseases, which continued for two weeks accounted for 74.8%, About 51.6% patients would choose to search for treatments and 64.4% of them would go to the second-stage health institutions, such as township hospitals and village clinics. The main reasons that rural patients failed to see doctors involved feeling their diseases slight by self-inductance, economic difficulty and non-effective measures, which accounted for 52.9%, 26.0% and 16.5% respectively. (3) The prevalence rate of gynecological tumor of rural women above 20-year-old was 4.7523 per thousand, among them the prevalence rate of malignant tumor was 1.6897 per thousand. The results of single factor analysis were as follows: the common gynecological tumor-related risk factors of rural women were dysmenorrheal, menopause, the use of postmenopausal hormone drugs, breast-feeding, contraceptive pill, gynecological inflammation, history of suffering from other chronic diseases and family history of cancer; the protective factor was pregnancy. The results of multivariate analysis showed that the common risk factors of gynecological tumor incidence of rural women were contraceptive use [OR=20.614, 95.0%CI (1.301 - 326.623) ] and gynecological inflammation [OR=31.635, 95.0%CI (1.836-544.966)] . (4) According to our investigation, 41.4% rural women in Liuyang city suffered reproductive tract infections, including chronic cervicitis and vaginitis, which were 68.3% and 31.1% respectively. The rural women who were 35 - 50-year-old had the highest reproductive tract infections rate 45.6%. The women who did occasional cleaning or non-cleaning had 1.59 times more risk in suffering the reproductive tract infections than those who did cleaning frequently and continually. Only 18.9% rural women wanted to go to hospital for treatment after they found they had reproductive tract infections symptoms.
Conclusion: (1)In 2006, the prevalence rate of chronic diseases of rural residents in Liuyang City is higher than that of the national rural residents in 2003 and the chronic diseases spectrum was similar to that of national rural residents. The 10 kinds of major chronic diseases exerted an extraordinarily significant and financial influence on the patients in rural areas in Liuyang City. (2) The chronic diseases took an extremely crucial role in threatening the health of the rural residents; the distance was the primary influential factor in choosing medical institutions; rural patients always abandon the treatment for several reasons, such as little consciousness of maintaining health, the economic burden of seeing doctors and the financial difficulties of curing chronic illnesses. (3) Suffering from gynecological inflammation were common risk factors of gynecological tumor. (4) The reproductive tract infections rate in Liuyang City was closed to the results of other domestic relevant surveys; the major and high-risk population to prevent reproductive tract infections was 35-50-year-old married women in rural areas; lacking personal health knowledge and positive sexual health habits played an exceedingly vital role in reproductive tract infections of rural women; the utilization rate of health services was low after the rural women suffered reproductive tract infections; the census and treatment policies conducted by Liuyang MCH hospital in the past ten years were still crucial and effective to improve the health status of reproductive tract infections of rural women.
Part 3 The survey of current status of rural health services of Township Hospitals and Village Clinics in Liuyang City
Objective: To investigate the present situations of sanitation resources and health service of township hospitals and Village Clinics in Liuyang City and to provide evidences for development of township hospitals and Village Clinics; To explore the current status about the child immunization and to provide evidences for evaluating the rural public health in rural areas of Liuyang.
Methods: The study was conducted by a general investigation to 36 township hospitals and 687 village clinics, concerning the infrastructure, health professionals, primary care, public health service and income / expenses. We surveyed the situation about the basic and strengthening immunization among 630 children, who were born between January 1, 2003 to December 31, 2005 in 3 townships involved Zhentou, Sankou and Yanghua. Then we made qualitative investigations about the professional training of planned immunization, vaccination management and data archiving.
Results: (1) The average coverage of these medical institutions was 36,790 persons, which means 1.5 professionals per thousand residents; the professionals working in the medical institutions of countries and townships accounted for 88% of the total staffs; the average person of public health personnel was 3.8 persons per hospital. In 2005 the sickbed utilization mean ratio was 58.9% and 184,639 patients received diagnosis and treatments per year. 2/3 income of township hospitals derived from vaccination in the recent five years. The maximum of personnel, sickbeds, operation areas and capital asserts were 196 person, 170 person, 10900 m~2 and 21.46 million yuan respectively. Oppositely the minimum of them were 7 person, 6 person, 400m~2 and 0.41 million yuan. (2) According to the investigation, there were 1,158 health professionals and 757 village doctors totally, which meant 0.89 health personnel and 0.58 village doctors were working for thousand residents. The village doctors who were over fifty years old accounted for 52.3%, and who lacked professional training accounted for 54.8%. The operation areas of village hospitals varied from 200m~2 to 1m~2, and 36.7% of them were lower than 45m~2. The capital asserts fluctuated from 1.5 million yuan to 10 thousand yuan. 76.8% of the entire income of village clinics rooted in the sales amount of medicines. The main public health services of village clinics included reporting epidemic situation, health education, informing vaccination and reporting birth and death and so on. (3) Three villages had 5 professionals serving rural dwellers according to the planned immunization program of a total population of 98,383 residents and the professionals ratio was 51 personnel per million citizens; among 3 age groups the average ratio of running the cards and certifications was 90.5% and 86.7% respectively. 75.06% of children in 3 age groups had full basic immunization, which involved Bacilli Calmette Guerin (BCG) vaccination 91.52%, Oral Polio Vaccine (OPV) 86.49%, Diphtheria Pertussis Tetanus (DPT) 83.91%, Measles Vaccines (MV) 81.08%. The rate that children accepted all the four vaccination was 79.35% in 2003, 76.74% in 2004 and 69.53% in 2005; the hepatitis B vaccination coverage rate was 84.3% and the coverage rate of strengthening immunization of DTP and MV were 48.6% and 50.2% among children all the three age groups; the running rate of card and certification of the floating population and the children who were born against one-child policy were only 57.4% and 74.4% and the four vaccination rate and hepatitis B vaccination rate of them were 42.6% and 48.9% respectively.
Conclusions: (1)The health resources of township hospitals are relative enough in Liuyang City; The developing trend of Liuyang township hospitals reveals polarization, which has affected the fairness and the availability of countryside primary care and public health service; The government investment is relative insufficient, which weakens the capability of public health service of township hospitals. (2)The obviously bipolar trend of medical hospitals in villages in Liuyang City would influence the equity and accessibility of rural basic diagnosis and treatments and public health services; The main function of village clinics were simply, mainly depending on the sales of medicine. The health personnel were elderly and lacked professional training. (3) In three townships investigated, the four vaccination rate showed a downward trend year by year, while strengthening vaccination rate was low in general; the townships workstations had a relative shortage of professionals, which led to the fact that the vaccination coverage radius was so large that the vaccinations of children in remote areas were not protected by the immune effects of the township planned immunization; the floating population and the children born against one-child policy were the weak points of the plan; the four vaccination rate was relevant to four factors, such as the professionals engaging in the vaccination enterprise, year of birth, place of birth and having vaccination card.
Part 4 The comprehensive analysis of rural health services investigation in Liuyang
1) Situation and challenges faced: (1)Chronic diseases had become the most essential factor threatening rural residents' health status. So heaviest burden was the economic burden after the rural patients suffered chronic diseases, and new rural cooperative institutions hardly help rural dwellers resist the risk of diseases. the utilization of health services was significantly restrained. (2) township hospitals are the main healthcare institution that rural residents utilize health service, the insufficient funding appropriation of rural health resulted in continuously tremendously bipolar trend between the formation and development of health institutions in countries and that in villages. Meanwhile, the weakness of rural public health services would significantly influence the public welfare of rural health institutions and the equity and accessibility of rural basic medical services and public health services.(3) The reproductive tract infections rate of married women in reproductive age and the incidence rate of both benign and malignant cancer of rural women are more important problem in Liuyang City. The health knowledge and behaviors were the main influential factors and the reproductive tract inflammation was the significant risk factor. But the utilization rate of health services of rural women's gynecopathy in Liuyang City was so low that the health prevention and protection of rural women suffered tremendous pressure. (4) The formation of professional team in rural sanitary organizations in Liuyang City failed to be reasonable. The staffs for medical treatments were sufficient, but the personnel working for public health and nursing care, who had higher commonweal and lower economic benefits, were relatively deficient to meet the standards of rural health services.
2) Policies recommended: (1) According to "rural health service system formation and development planning", we could institute the construction standards of medical institutions in countries and townships and standardize the establishment of rural sanitary organizations; we could increase the fund that government appropriated to the hospitals in rural and remote areas and decline the gap between the medical institutions in countries and that in villages; we could enlarge the supplement, training and evaluation of service personnel in village stations and ensure all the rural dwellers could share fairly basic medical treatments and public health services. (2)We could transform the mode of medical institutions in countries and townships to the style of community health services, and strengthen the public health services functions of medical institutions and clinical doctors in countries and villages. We could also enlarge the fund appropriation for public health services and the total number of professionals and increase the level of planned immunization, disease prevention and women and children health care, it can enhance the commonweal of rural health service. (3) The most primary responsibilities as the doctors in medical institutions of countries and townships was to control and govern the prevention and medial expenses of chronic diseases and to increase the health level of rural dwellers. (4) It is recommended that the insurance standards of new rural cooperative institutions should not be lower than that of townsmen,. Make sure the rural dwellers can receive beneficial treatments in time, which would help farmers resist the risk of serious illness. (5) We could increase focus on the cyclical health examinations of high-risk and crucial population to ensure early discovery, diagnosis, treatment and control.
3) Discuss of research achievement and deficiency: (1) Through the systematic survey of the main health problem of rural dwellers, the need assessment and the utilization of health services, the financial burden of diseases, the health resources allocation and situation of medical institutions in countries and townships, we could basically understand the current problem and pressure existing in the rural medical enterprise in Liuyang City, to provide a theoretical evidence for the rural health development plans and the establishment of the local health policies. However, the present investigation did not involve the quality of rural medical health services and the situations about rural mental health, which are the focus of further study. (2) On the basis of the comprehensive survey of public health services, the economic balance and the professionals, we surveyed the basic immunization coverage rate and its influential factors about rural children, to evaluate the development and implementation of the core work of public health services. Through the study, we found several deficiencies in the current rural public health services system and provided the theoretical references for the reasons of the deterioration of the rural public health care and the direction of further implements, but the evaluation of the implementation and effectiveness of the rural public health services needs more comprehensive indexes to be reflected correctly and precisely.
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